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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293619699
Report Date: 12/02/2022
Date Signed: 01/24/2023 09:04:58 AM


Document Has Been Signed on 01/24/2023 09:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:FREY, BRENDAFACILITY NUMBER:
293619699
ADMINISTRATOR:FREY, BRENDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 477-0382
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY:14CENSUS: 9DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Victoria VignauTIME COMPLETED:
12:35 PM
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Upon arrival, Licensing Program Analysts (LPA) Matthew Gallo and Amanda Blesi met with employee, Victoria Vignau, for the purpose of an unannounced Annual/Random inspection. Additional assistant also present upon arrival, and licensee arrived in the middle of the visit. All individuals subject to criminal background review have obtained a criminal record clearance. Today’s census was 4 infants and 5 preschool age children.

Operating hours are 7:00am to 5:00pm, Monday through Friday.

A health and safety inspection was conducted in all areas accessible to children. Previously, off-limits areas included the Son's Bedroom. During visit, Licensee made decision to return Son's Bedroom back to an on-limits area. Going forward, there will be no off-limit areas in the house.

LPAs observed a working phone, fire extinguisher, and functioning smoke and carbon monoxide detectors.

Licensee stated there are no weapons in the home. Toxic and hazardous items (detergents, cleaning compounds, medications, sharp utensils, items that could pose a danger to children in care) are properly stored and inaccessible to children. There is no fireplace at the home. There are no stairs in the home. Safe toys and play equipment are observed.

The outdoor play space is fenced. The Licensee understands that in unfenced outdoor areas, 100% supervision of children is required. There is a spa at the home. The spa is covered and locked on all sides.

Children’s files were reviewed. A current roster is being maintained. Licensee's fire and disaster drills are conducted and documented. Staff files were reviewed, revealing that Staff 1 and Staff 2 members were both missing MMR, and Staff 2 was missing Tdap as well.

*Continued on LIC 809-C
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: FREY, BRENDA
FACILITY NUMBER: 293619699
VISIT DATE: 12/02/2022
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This provider is currently not providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA discussed the Safe Sleep in Child Care and ensured licensee understood all regulations.

LPA reviewed and discussed this facility evaluation report with the Licensee. LPA provided a Notice of Site Visit and the Licensee acknowledges that this notice should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at http://ccld.ca.gov for child care updates, current forms, legislation and regulation information.



In the areas that were evaluated, one Type B deficiency was observed during the course of the visit regarding missing immunizations of Staff 1 and Staff 2.

The Licensee's signature on this form acknowledges receipt of this form.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2023 09:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: FREY, BRENDA
FACILITY NUMBER: 293619699

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff records which poses/ a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2023
Plan of Correction
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Licensee will provide proof of completed immunizations to LPA Gallo by email at matthew.gallo@dss.ca.gov or text at 916-208-3734
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
LIC809 (FAS) - (06/04)
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